Committee continues to look at alternative Medicaid expansion

As an estimated 18,000 uninsured residents continue to put pressure on medical providers in Wyoming, especially the state’s rural hospitals, as members of the Joint House Labor, Health and Social Services Committee search for answers that will provide health coverage to those individuals, without placing an overwhelming burden on the state’s resources.

Rep. Elaine Harvey

According to the committee’s co-chairman, Rep. Elaine Harvey of Lovell, that search becomes more critical each day as rural hospitals, including those serving her constituents in Big Horn and Park counties, continue to show losses.

“Though I am very much against Medcaid expansion, I’m worried about the future of our rural hospitals,” said Harvey.

Harvey said her committee has been studying alternative expansion programs launched in other states for about four years now and efforts continue to devise a plan that would work in Wyoming. Since Wyoming has yet to allow an expansion program, many are caught in the middle without health care coverage because they are too poor to purchase insurance on the Affordable Health Care exchange but not poor enough for the regular Medicaid program.

Harvey said a number of programs are being considered and she expects to see at least one or more bills addressing the issue at the upcoming legislative session in January and February of 2015.

One of those programs was endorsed recently by Gov. Mead, who has been a staunch opponent of any kind of Medicaid expansion in the state. The plan differs from the federally prescribed program in that it requires participants to pay a premium and copays for their coverage.

“This is kind of a hybrid of several different other state programs,” explained Harvey. “One of them is Indiana and that’s where the participants are linked with work assistance benefits. The personal responsibility is that they have copays and premiums to pay.”

Harvey expressed her concern that the people eligible for the plan are so low income that they would not be able to afford something as small as a $4 copay or a $20 per month premium.

“We’ve tried co-pays before and I feel like we are trying to repeat history again,” said Harvey. “What happens in reality is that these folks are so low income that it could stop them from going to the doctor’s office because they don’t have the $4 to pay for the copay or they go to the doctor’s office anyway and don’t pay, making the doctor accept an even lower reimbursement rate.

“We tried copays before. We tried it with prescriptions, and it wasn’t highly successful then but the landscape has changed so maybe we can make it successful now.”

Harvey explained that two types of groups involved in the plan supported by both the governor and a recently released report issued by the State Dept. of Health.

The group would involve individuals age 21 – 64 who have incomes that are 101 to 138 percent of the federal poverty level. These individuals would be eligible for a special “demonstration waiver” and they would, in effect, pay a very small premium to become eligible for something similar to the federal Medicaid program. Because it is a program “outside” of the normal rules of the new Affordable Care Act (known to many as Obamacare), it is allowed for a period of time, giving the state an opportunity to “demonstrate” that it works.

The recipients would be able to access healthcare through Medicaid’s provider network. The Medicaid program would administer the plan, the difference being that, unlike a straight Medicaid expansion, they would be required to pay a nominal premium similar to an insurance premium.

The benefits package would be equal to the “essential health package” that people across the country are currently buying on the federal exchange. It would also pay for family planning.

According to the report released by the Dept. of Health, the cost of premiums range would from around $20 to $50 per month. Participants lose their coverage if they don’t pay their premiums for 90 days. The copayments and premiums cannot exceed 5 percent of the individual’s annual income, which is often in the $12,000 range.

If the person meets certain health “milestones” like quitting smoking, losing weight or reducing cholesterol they get a reduction in their premium contribution for the next year.

In order to participate individuals will be subject to a comprehensive health assessment during the application process and they have to get a physical exam every year, which may include blood work and other medical tests.

“The idea is to incentivize people to be healthy,” said Harvey.

The health assessment also helps identify a special sub-group of individuals who are “medically frail.” Those individuals are put into a different health plan, similar to conventional Medicaid but with intensive case management.

“These individuals are very low income with complex healthcare needs,” explained Harvey. “The individual would be provided with case management.”

The proposed program provides 10 essential health benefits, similar to what is already offered through standard federal Medicaid program that operates in the state. What differs from the federal program is the personal responsibility of paying for some of the costs and the incentives for living a healthier lifestyle.

As the annual legislative session nears, the committee is ramping up its efforts to present at least one bill, to stimulate discussion and possibly resolve the matter.

Harvey said though she is very much against Medicaid expansion due to concerns that the federal government won’t be able to keep up its end of the bargain, she is equally concerned for rural hospitals that are taking the hit on their bottom line when the uninsured in this very low income category seek services but are not able to pay for them.

An estimated 18,000 individuals in Wyoming fall into this category, along with another 2,000 with mental health needs.

“There is a big gap in wages in our state between people who work in high paying jobs in the oilfields making $30 to $50 per hour and waitresses who make $2.58 per hour,” said Harvey. “As long as people are working and trying to better themselves, I think it’s important to keep them healthy enough to work.”

Harvey said she supports a plan that requires individuals to seek work-assisted benefits like help with job searches, vocational rehabilitation and job training. These programs are already in existence but are underutilized by this population, she said.

She said the committee is looking at adding provisions to the plan including a medical savings plan. The governor’s proposed plan already includes a work provision for those who are physically able to work.

The committee will meet again on Dec. 15 and 16 to discuss all of the alternatives that could work in the state, which has some of the highest insurance rates in the country and very limited medical resources available due to its low population.

Harvey expressed her concern that changes to the Affordable Care Act are surely on the horizon, creating uncertainty for any program.

“I am deeply concerned that if the federal government’s share of the cost drops below 90 percent, it will place too much pressure on the state,” she said. “Clearly if that happens, whatever program is in place will have to stop. This has been my concern all along, and the concern of many others.”